Block 10.0 Part I
What is the difference between ARF and ARDS?
-ARF=due to inflammatory response -ARDS=due to other outlying response/not responding to 100% oxygen
What medication is given for Supraventricular Tachycardia? Why?
-Adenosine -Helps slow down heart/jump starts the heart to help determine the underlying rhythm because it is hard to "P" wave and if you slow it down, it'll help you to determine if this is an SVT or something else
What are some surgical procedures for a patient with sleep apnea?
-Adnoidectomy -UPP -uvulectomy (Taking out tissue)
What are the class of drugs that help treat PE?
-Anticoagulants -Fibrinolytics
What are some important things to monitor in a patient in Neurologic Shock?
-Aspiration -Respiratory status
What are some early s/s of tension pneumothorax?>
-Asymmetry of thorax -Respiratory distress -Hypotension -Absence of breath sounds on one side -Distended neck veins (Circulation ↓ = pulmonary congestion) -Hypertympanic sound to percussion
What are some late s/s of tension pneumothorax?
-Cyanosis (Later symptom) -Tracheal movement away from midline toward unaffected side (as well as lung)
What are some things that would cause a LOW pressure ventilator alarm to occur?
-Disconnection -Extubation -Leak
What are some other interventions for a patient experiencing a Flail chest?
-If they aren't ventilating appropriately = atelectasis or pneumonia -Incentive Spirometer -Need to be up/going, walking -Monitor pneumothorax
What are s/s of febrile transfusion reaction?
-Increase temp -Increase fever
What are some things that would cause a HIGH pressure ventilator alarm to occur?
-Kinked tubing -secretions -coughing -biting -bronchospams -primary edema -pneumothorax
What are some early s/s of HIV? What are some late phases?
-Low grade fever, flu-like symptoms, tired, malaise -repeat yeast infections, general herpes
What medication is used for ICP?
-Mannitol (helps decrease amount of fluid in skull)
What are surgical interventions for a patient with Trigeminal Neuralgia?
-Microvascular decompression (go in through skull to move vessel off of nerve) -Radiofrequency waveforms -Rhizotomy -Glycerol injections
What are some treatment options for a patient that is experiencing a Flail chest?
-Oxygen -Splint chest when coughing if ribs are broken
With ARDS the patient is __________________ _________________
-Persisting hypoxia (even with 100% oxygen) (hypoxia is defined as the reduction of oxygen supply at the tissue level)
What are some s/s of autonomic dysreflexia?
-1st sign: Severe headache -Increased BP -Flushed skin -Decreased HR -Sweating above SCI
What causes ARF?
-Prolonged inflammation -acute bronchitis -asthma -ABG inflammation (respiratory acidosis)
How is ARDS treated?
-Respiratory assistance (like a entubation/ventilator) w/ PEEP (Positive End Expiratory Pressure) and soft wrist restraints
What does a retrovirus do? what do they attack?
-Takes RNA and makes own DNA -CD4 cells and T-cells
What are some treatments for a patient with C.diff?
-antidiarrheals -vancomycin -maintain fluid/e' balance -fecal transplant
What are s/s of C.diff.?
-diarrhea -dehydration -e' imbalances -bloody stools
What are some s/s of AIDS?
-diarrhea -extreme weight loss (wasting) -abdominal pain -infections of mouth/esophagus
Why would a patient need TPN or PPN?
-dysfunctional/nonfunctional GI tracts -bowel rest -Nutritional deficient
What causes ARDS?
-fluid leaks into the lungs making breathing difficult or impossible.
What are s/s of sleep apnea?
-morning headache -daytime sleepiness
Protease inhibitors end in what suffix?
-navir
What does high pressure mean when suctioning? What do you do to fix?
-obstruction (need to suction) -kink in tubing -mucous buildup get new tube or figure out what is causing obstruction
What can are some complications with a trachyostomy?
-pneumothorax -subQ emphysema (look for crackles, bubble wrap) -Bleeding -Infection
What are some complications associated with TPN/PPN?
-pneumothorax -Air embolism -hyper/hypoglycemia -hypervolemia -Infection: change tubing q24hr -Re-feeding syndrome: massive electrolyte changes -hyponatremia, hyper/hypokalemia due to glucose/insulin -hypercalemia
What are some metabolic complications with TPN/PPN?
-sepsis (caused from dextrose contained in TPN) -electrolyte imbalances -hyper/hypoglycemia -hypervolemia -hyperosmolar diuresis (BP, HR, v/s)
Why is a "drug cocktail" used in patients with AIDS?
-slows viral replication
What is maintenance when it comes to upper airway obstruction?
-tracheostomy -endotrach -cricothyroidotomy
Stage 2 of HIV has a CD4+ T-Lymphocyte Count of
200-499 cells/mm^3
Stage 3 of HIV has a CD4+ T-Lymphocyte Count of
< 200 cells/mm^3
When should PRBC be administered and how long should it be administered for?
<30 min from time you remove from fridge 2-4 hours
Stage 1 of HIV has a CD4+ T-Lymphocyte Count of
> 500 cells/mm^3
What is autonomic dysreflexia?
A condition in which involuntary nervous system overreacts to external or bodily stimuli causing uncontrolled hypertension
What are the main causes of A. Fib?
electrolyte imbalances low oxygen
A synchronized cardioversion is used to correct ________________.
A-fib
What is the priority for a patient that has recently had a SCI?
Airway
What medication is used for a patient experiencing asystole?
epinephrine
What are the main assessments in a patient with a Spinal Cord Injury?>
ABCDs
If there is a spike before the the "P, QRS wave" in an EKG, what type of pacemaker is this?
AV pacemaker
A patient that is always hypoxemic is suffering from ________________________________________________.
Acute Respiratory Failure (ARF)
What medication is used to treat Supraventricular Tachycardia?
Adenosine
For a patient experiencing stable (asymptomatic) Ventricular Tachycardia w/ a pulse, what vitals/ s/s would you see?
Alert/Orientated Decrease BP
What medications/interventions would you use on a patient that is experiencing unstable (symptomatic) Ventricular Tachycardia (w/ a pulse)?
Amiodarone Cardioversion
What does viral load mean?
Amount of viruses being replicated within cells
_______________ is an examination by X-ray of blood or lymph vessels, carried out after introduction of a radiopaque substance.
Angiography
If there is a spike before the the "P wave" in an EKG, what type of pacemaker is this?
Atrial pacemaker
What medication is used to treat Sinus Bradycardia?
Atropine
A nurse is caring for a client who has a hard cervical collar for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air
B
What is a must have vital sign before giving a Calcium Channel Blocker? What will this medication do?
BP decrease HR
Why isn't doing caridoversion on a patient after 24 hours of experiencing A. Fib a good idea?
Because of stroke and PE
What are treatment medications for a person experiencing A. Fib?
Beta Blockers CCB K+ Channel Blockers
How to tell from a EKG if a patient is undergoing Supraventricular Tachycardia
By narrow QRS tachycardias
Which heart procedure uses a bypass graft?
CABG
Pacemakers are used for patients with _______________________
CAD (or sinus bradycardia?)
What is the difference between HIV and AIDS?
CD4 count <200 or Opportunistic infections
What interventions are important in a patient that is experiencing asystole?
CPR Medications --> (epinephrine)
What medications/interventions would you use on a patient that is experiencing unstable Ventricular Tachycardia (w/out a pulse)?
CPR!
A patient has an M.I., which is the priority? Administer atropine or cardiac catheterization?
Cardiac catheterization
If a patient is experiencing SVT with an underlying A. fib., and the patient is stable (asymptomatic), what is the best treatment option?
Cardioversion
A client who sustained a recent cervical spinal cord injury reports feeling flushed. The client's blood pressure is 180/100. What is the nurse's best action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Turn on a fan to cool the patient. D. Place the patient in a sitting position.
D
For a patient experiencing unstable Ventricular Tachycardia (w/ a pulse), what vitals/ s/s would you see?
Decrease BP Decrease LOC
What is a AICD (automated implantable cardiac device?
Defib/Pacemaker -helps set rhythm/prevents from going too slowly -helps fix arrhythmia
______________ is an HIV antibody screening test
ELISA
A _________________Hemorrhage is when bleeding occurs between the tough outer membrane covering the brain (dura mater) and the skull
Epidural Hemorrhage
A _________________ Hemorrhage is a collection of blood in the 'potential' space between the skull and the outer protective lining that covers the brain (the dura mater).
Extradural Hemorrhage
When a patient has low plasma volume what types of blood products should this patient receive?
FFP, PRBC, Plasma
If a patient is experiencing asytole, the nurse should use a defib? True or False
False
Fluconazole (Diflucan) targets ______________ .
Fungi
What are some things to monitor for for a patient receiving TPN/PPN?
Glucose I/O Daily weights Labs: Na+/K+ (Ca2+ sometimes) -weekly 24 hour urine -Bi-weekly: nutritional assessment
What is a must have vital sign before giving a Beta Blocker?
HR decrease BP
Chest Drainage system: If there is gentle bubbling in the suction control chamber, this means...?
Helps tell if device is correctly suctioning
What condition should a patient receive clotting factors?
Hemophilia
What lab values do you check after Post-Transfusion of blood products?
Hgb Hct electrolytes (Na, K)
TPN is hypertonic, hypotonic or isotonic solution?
Hypertonic
What medications/interventions would you use on a patient that is experiencing stable (asymptomatic) Ventricular Tachycardia w/ a pulse?
Medications: -Amiodorone -MgSO4 -Beta Blockers, CCB (Depends) Oxygen therapy Treating electrolyte imbalances
What is the lab value to look at before giving Warfarin? What is the antidote?
INR Vitamin K
What are the main s/s (v/s) if ICP?
Increased Temp Increased BP Decreased Pulse Decreased Respirations
A ________________ Hemorrhage is bleeding around or within the brain itself.
Intracerebral hemorrhage
A ________________ Hemorrhage is all bleeding within the skull
Intracranial hemorrhage
PPN is hypertonic, hypotonic or isotonic solution?
Isotonic
What are medications that help in Traumatic Brain Injuries?
Mannitol Lasix Dilantin or phenobarbital Opioids
After 24 hours of A.Fib. the best intervention is...?
Medications
What are medications given when a patient is experiencing M.I.?
Morphine Oxygen Nitroglycerin Aspirin
Delavirdine (Rescriptor), Efavirenz (Sustiva), & Nevirapine (Viramune) are all _____________________ Reverse Transcriptase Inhibitors
Non-Nucleoside
Zidovudine (AZT, Retrovir) is a _____________________ Reverse Transcriptase Inhibitor.
Nucleoside
Chest Drainage system: If there is no bubbling in the water seal chamber, this means...?
Obstruction
What are the v/s to access during suctioning a patient?
Oxygen HR
What assessment would you want to do before an IV push?
Oxygen, BP
A Fib doesnt have a distinct _____________ wave.
P
Where can TPN be administered and why?
PICC or Central line (NO PIV) TPN is Hypertonic
What is autologous transfusion mean?
PT donates their own blood and recieve his/her own blood during a procedure
__________________ is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.
PTCA
What is the lab value to look at before giving Heparin? What is the antidote?
PTT Protamine Sulfate
What is the test used to diagnose a patient with sleep apnea?
Polysomnography
Atazanavir, nelfinavir, saquinavir, & indinavir are all __________________?
Protease Inhibitors
What respiratory conditions manifests petchiae?
Pulmonary Embolism
Atropine is given in what cardiac complication(s)?
Sinus Bradycardia
what heart condition may require a pacemaker?
Sinus Bradycardia
A ________________Hemorrhage is bleeding in the space between the brain and the tissue covering the brain.
Subarachnoid Hemorrhage
A ________________ Hemorrhage, is a pool of blood between the brain and its outermost covering.
Subdural Hemorrhage
Adenosine is given in what cardiac complication(s)?
Supraventricular Tachycardia (SVT)
With a synchronized cardioversion, you want to avoid ________ wave so it doesnt cause V-fib
T
Chest Drainage system: Ifthere is lots of bubbling in the water seal chamber, this means...?
There's a leak
_______________ is a Supplemental HIV antibody test
Western Blot (Indirect Immunofluorescence Assay [IFA])
What condition is caused by vascular compression on 5th cranial nerve?
Trigeminal Neuralgia
If a patient is experiencing V.Fib., the nurse should use a defib? True or False
True
What cardiac conditions would you want to use Cardioversion?
V Tach w/ pulse A.Fib.
What cardiac conditions would you want to use a Defibrillation devise?
V Tach w/out pulse V.Fib
With a synchronized cardiogram, you want to avoid the "T" wave so it doesnt cause _____________________ to occur
V-fib
Tensilon test places a client at risk for ___________________________ and ________________________ (heart related conditons).
V.Fib Cardiac Arrest
Amiodarone is given in what cardiac complication(s)?
Ventricular Tachycardia (V.Tach) Ventricular Fibrillation (V.Fib) Asystole
Lidocaine is given in what cardiac complication(s)?
Ventricular Tachycardia (V.Tach) Ventricular Fibrillation (V.Fib) Asystole
If there is a spike before the the "QRS complex wave" in an EKG, what type of pacemaker is this?
Ventricular pacemaker
Chest Drainage system: Why does the suction ball rise and fall and what is this rise/fall called?
When you take a breath -tidaling
Chest Drainage system: If there periodic bubbling in the water seal chamber this means...?
Working normal
A client with Guillain-Barre syndrome has been intubated for respiratory failure. The nurse must suction the client. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the client for? a. Bradycardia b. Atrial fibrillation c. Tachypnea d. Cyanosis
a
For a client undergoing external radiation therapy, what do the nurse's instructions include? (Select all that apply.) a. Avoid wearing belts or clothing that binds the irradiated area b. Do not remove the markings c. Use mild soap and water on the affected skin d. Use lotions liberally to keep skin soft and moist e. Avoid direct skin exposure to sunlight for up to a year f. Gently rub treated areas to stimulate circulation
a, b, c, e
What information can be obtained by surgical staging? (Select all that apply.) a. Assessment of tumor size b. Number of tumors c. Sites of tumors d. Types of tumors e. Pattern of spread of tumors f. Pain related to tumors
a, b, c, e
Which practices are generally recommended to prevent sexual transmission of HIV? (Select all that apply.) a. Use of a latex barrier for genital and anal intercourse b. Use of latex gloves for finger or hand contact with the vagina or rectum c. Use of antiviral medications taken on a precise schedule d. Use of latex condoms for genital and anal intercourse e. Use of natural-membrane condoms for genital and anal intercourse f. Use of an appropriate water-based lubricant with a latex condom
a, b, d, f
Which statements about the transmission of HIV are true? (Select all that apply.) a. An undetectable viral load requires greater or multiple exposures. b. All people infected with HIV can easily infect others with AIDS. c. HIV is transmitted through touching an infected person. d. Those with recent HIV infection and high viral load are very infectious. e. HIV may be transmitted only during the end stages of the disease. f. Those with end-stage HIV and no drug therapy are very infectious.
a, d, f
Although there is a wide range of time from the beginning of HIV infection to the development of AIDS, which client is most likely to develop AIDS very quickly? a. Adult male who is transfused with HIV-contaminated blood b. Older nurse who is stuck by HIV-contaminated needle at work c. Older male who has vaginal sex with an HIV-positive female d. Adult female who has one-time sex with an HIV-positive partner
a.
Which cancer client has the highest risk to develop sepsis? a. An 82-year-old client with neutropenia and a low-grade fever b. A 53-year-old client with small cell lung cancer and hyponatremia c. A 34-year-old client who has received high-dose radiation to the upper chest area d. A 66-year-old client with hypercalcemia and dehydration
a.
The nursing assessment indicates that a client has increased intracranial pressure with ptosis, dilated and non-reactive pupils, and decreased level of consciousness has decreased. The nurse's top priority action is to: a. notify the physician b. administer IV diazepam (Valium) c. administer IV phenytoin (Dilantin) d. Document these findings as the only action
a. A change in level of consciousness (LOC. is the first indicator of neurologic decline. (Ignatavicius 926)
The primary home caregiver brings his mother to the clinic with complaints of her wandering around at night, forgetting appointments, forgetting to take medications, and confusing family members with older relatives from the 1940's era. a. Alzheimer's b. Guillian Barre c. Myasthenia Gravis d. Parkinson's Disease
a. AD is manifested by loss of memory, judgment, and visuospatial perception and by a change in personality. Over time, the patient becomes increasingly cognitively impaired. (Ignatavicius 946). Key features are listed in Chart 44-12 on p. 948.
When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to: a. Stop the infusion if swelling is observed at the site. b. Infuse the medication over a short period. c. Administer the chemotherapy through small-bore catheter. d. Hold the medication unless a central venous line is available.
a. Swelling at the site may indicate extravasation, and the iv should be stopped immediately. The medication should generally be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running iv line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices (cvads) are preferred.
A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is: a. "why don't we talk about the options you have for the care of your children?" b. "many patients with cancer live for a long time, so there is time to plan for your children." c. "for now you need to concentrate on getting well, not worry about your children." d. "perhaps your ex-husband will take the children when you can't care for them."
a. This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "many patients with cancer live for a long time" and "for now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.
With ARF the patient is __________________ _________________
always hypoxemic (PaO2 <60)
What two medications are usually given with V.Fib.
amiodarone epinephrine
What is a hemolytic reaction?
antibodies cause reaction and lysis of RBC occurs releasing K+ and can cause renal issues (flank pain, panic, decrease in urinary output)
When should TPN and lipids be removed from fridge?
at least 1 hour before infusing
A patient has Sinus Bradycardia, which is the priority...administer atropine or cardiac catheterization?
atropine
What drug treatment is used for Sinus Bradycardia?
atropine
The nurse is caring for a patient with a diagnosis of multiple sclerosis (MS). The patient is worried about the recurrent disease exacerbations and associated fatigue. The nurse should suggest which of the following interventions to help at home? a. Limit activites and take morning and afternoon naps b. Space activities throughout the day with opportunities for rest c. Identify where assistive devices can be obtained at reasonable price d. Ask patient's mother to help with the children in the evening
b
What diagnostic test is used to differentiate a cholinergic crisis from a myasthenic crisis? a. Electrophysiologic studies b. Tensilon challenge testing c. Cerebral spinal fluid protein level d. Repetitive nerve stimulation
b
Which conditions may be the first signs of HIV in women? (Select all that apply.) a. Spontaneous abortion b. Vaginal candidiasis c. Genital herpes d. Mononucleosis e. Bladder infection f. Pelvic inflammatory disease
b, c, f
The nurse is caring for a client with a recent spinal cord injury (SCI). Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? (Select all that apply). a. Keep the client immobilized with neck or back braces b. Maintain stable environment temperature c. Frequently perform passive range of motion exercises d. Monitor urinary output and check for bladder distention e. Monitor stool output and maintain a bowel program f. Loosen or remove any tight clothing
b, d, e, f
A client is diagnosed with Pneumocystis jiroveci pneumonia. Which signs and symptoms does the nurse expect to find when assessing the client? a. Substernal chest pain and difficulty swallowing b. Dyspnea, tachypnea, persistent dry cough, and fever c. Fever, persistent cough, and vomiting blood d. Cough with copious thick sputum, fever, and dyspnea
b.
A client who is HIV positive has been taking combination antiretroviral therapy (cART) for several years. Today the nurse sees that the test results now show a CD4+ T-cell count of less than 200 cells/mm3. Which intervention is the nurse most likely to perform? a. Reinforce the client's successful compliance with medication regimen b. Provide emotional support when the client is informed about AIDS diagnosis c. Emphasize need to practice safe sex because risk of transmission is high d. Assess the client's understanding of the importance of the medication schedule
b.
An older adult client is brought to the clinic by the family, who reports that, "Dad doesn't seem to be quite like himself." Which behavior is an early sign of a neurologic problem? a. Inability to describe his favorite hobby b. Inability to remember a trip that he took last week c. Failure to recall where he went to high school d. Failure to remember his mother's maiden name
b.
The healthcare provider is providing teaching on pleural effusions. The healthcare provider understands that teaching has been effective when the patient states: a. "A pleural effusion is accumulation of fluid in the airways of the lungs." b. "A pleural effusion is an accumulation of fluid in the pleural cavity." c. "A pleural effusion is an accumulation of fluid in the alveoli." d. "A pleural effusion is an accumulation of blood in the airspace."
b.
The healthcare provider tells the nurse that the client is considered stage I according to Centers for Disease Control and Prevention case definition for HIV disease. What would the nurse expect to find when assessing the client? a. Signs and symptoms associated with Kaposi's sarcoma b. No signs or symptoms of AIDS-defining illness c. Symptoms of AIDS wasting syndrome d. Respiratory symptoms due to pneumonia
b.
The nurse is assessing a client whose lifestyle creates a high risk for HIV/AIDS. Which assessment is the nurse most likely to perform to differentiate HIV from AIDS? a. History of substance or alcohol abuse b. Signs/symptoms of opportunistic infections c. Practice of safe versus risky sexual behaviors d. History of any occupational exposure to HIV
b.
The student nurse is caring for a client with encephalitis. Which action by the student nurse warrants intervention by the supervising nurse? a. Performs deep suctioning for copious secretions in the airway b. Elevates the head of the bed 30 degrees after a lumbar puncture c. Performs a neurologic assessment every 2 hours d. Encourages and helps the client to turn every 2 hours
b.
What does the QRS complex represent? a. "The repolarization of the His Purkinje system happens here." b. "Ventricular depolarization and atrial repolarization occur during this time." c. "Atrial depolarization and AV node stimulation are occurring at this time." d. "This represents early repolarization of right and left ventricles."
b.
What is the most important means of preventing HIV spread or transmission? a. Genetic research b. Education c. Medication therapy d. Standard precautions
b.
Which malignancy is most common in clients with HIV/AIDS? a. Anal cancer b. Kaposi's sarcoma c. Primary brain cancer d. Non-Hodgkin's B-cell lymphoma
b.
Which statement correctly describes metastatic tumors? a. They become less malignant over time b. They are caused by cells breaking off from the primary tumor c. They are usually less harmful than a primary tumor d. They become the tissue of the organ where they spread
b.
While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumor: a. Do not cause damage to adjacent tissue. b. Do not spread to other tissues and organs. c. Are simply an overgrowth of normal cells. d. Frequently recur in the same site.
b. The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.
what class of drug is atropine? what does atropine do?
beta agonist increases heart rate
The client with multiple sclerosis has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication? a. Have the client stand and close eyes, and observe the client for sway b. Watch the client walk and note smoothness of movement c. Check the client's gag reflex and ability to swallow d. Ask the client to use a pencil to write a sentence
c
Which of the following statements made by a patient diagnosed with multiple sclerosis (MS) would alert the healthcare provider that the patient requires additional instruction about the disease? (Select all that apply) a. "It's important for me to inspect my skin daily make sure there aren't any injuries." b. "Regular exercise can help reduce fatigue and help improve my sense of balance." c. "I will avoid foods that are high in fiber to prevent problems with my bowels." d. "A hot bath in the evenings will help relax my muscles and relieve pain." e. "Use of stress reduction strategies can decrease the severity of my symptoms."
c, d
A client arrives in the emergency department reporting headache, fever, nausea and photophobia. The client has been living with 2 people who were diagnosed with meningitis. Which diagnostic test does the nurse anticipate the healthcare provider will order to rule out meningitis? a. Cerebral angiogram b. Myelography c. Lumbar puncture d. X-rays of the lumbar spine
c.
The nurse clarifies that a patient with HIV does not necessarily have AIDS until: a. Two or more opportunistic infections are diagnosed. b. The appearance of Kaposi's sarcoma. c. The CD4 cell level drops to 200. d. There is a positive ELISA.
c.
What is the major side effect that limits the dose of chemotherapy? a. "Chemo brain" b. Nausea and vomiting c. Bone marrow suppression d. Peripheral neuropathy
c.
Which cancer client is the most likely candidate for palliative surgery? a. Needs extensive cosmetic repair after treatment of neck cancer b. Has a suspicious skin lesion that requires further investigation c. Has continuous vomiting because tumor is obstructing the intestines d. Has been treated for cancer and is currently asymptomatic
c.
Which information can be obtained from grading a tumor? a. Location and origin of metastasis b. How long the cancer has been present c. Evaluating prognosis and appropriate therapy d. Genetic linkage to the cancer
c.
A client is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause an adverse effect. Therefore, the nurse should prepare the client to expect: a. Hair loss b. Stomatitis c. Fatique d. Vomiting
c. Fatigue, skin toxicities and anorexia at any site. The other options are incorrect.
A client with a nagging cough makes an apppointment to see the physician after reading that this is one of seven warning signs of cancer. What is another warning sign of cancer? a. Persistant nausea b. Rash c. Indigestion d. Chronic ache or pain
c. Indigestion is one of the seven warning signs, along with change in bowel and bladder habits. The other options are incorrect.
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a. To reduce intraocular pressure b. To prevent acute tubular necrosis c. To promote osmotic diuresis to decrease ICP d. To draw water into the vascular system to increase blood pressure
c. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern. (p. 1028, Ignatavicius)
The most important intervention for the client with Acute Respiratory Distress Syndrome (ARDS) is to administer: a. Antibiotics b. Bronchodilators c. Oxygen d. Diuretics
c. Respiratory failure is further defined as ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure. Whatever the underlying problem, the patient in acute respiratory failure is always hypoxemic (has low arterial blood oxygen levels). (Ignatavicius 670). Oxygen therapy is appropriate for any patient with acute hypoxemia. It is used in acute respiratory failure to keep the arterial oxygen (PaO2) level above 60 mm Hg while treating the cause of the respiratory failure. Oxygen therapy is discussed in Chapter 30. If oxygen therapy does not maintain acceptable PaO2 levels, mechanical ventilation may be used. (Ignatavicius 671)
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? a. Muscle atrophy b. Dementia c. Vision loss d. Clonus
c. Vision loss and eye pain (optic neuritis) are early symptoms of MS. Dementia is uncommon and found only in severely affected patients. Clonus (rhythmic contractions when a muscle is stretched) is a sign of nerve damage which may be seen as MS progresses. Muscle atrophy is also a later sign of MS which is caused by disuse of a muscle group.
When a client is receiving total parenteral nutrition, it is important for the nurse to assess the: a. Stool of occult blood b. Abdomen for bowel sounds c. Blood for glucose d. Arterial blood gas
c. Monitor for these complications by taking daily weights and by recording accurate intake and output while the patient is receiving parenteral nutrition. Serum glucose and electrolyte values are also monitored (Chart 63-6). (Ignatavicius 1348)
Within the first 24 hours of A.Fib. the best intervention is...?
cardioversion
For hemophilia patients which type of blood products will be given?
coagulation factors
What s/s are most common with circulatory overload?
coughing edema JVD
A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A. The client can reduce the dosages of the prescribed drugs. B. The virus is resistant to the current combination of drugs. C. The client no longer has AIDS. D. The drug therapy is effective.
d
A client is admitted for a closed head injury sustained during a fall down the stairs. The client has no history of respiratory disease and no apparent respiratory distress. However, the healthcare provider orders oxygen 2 L via nasal cannula. What is the nurse's best action? a. Use pulse oximeter and apply the oxygen if the saturation level drops below 90% b. Apply nasal cannula as ordered and wean from oxygen when client is discharged c. Question the order because oxygen is unnecessary and therefore an extra cost to the client d. Deliver oxygen as ordered because hypoxemia may increase intracranial pressure
d
A patient with spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor for which of the following manifestations? a. Tachychardia b. Hypotension c. Cyanosis of Head and Neck d. Severe, throbbing headache
d
A client has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the nurse is performing the change of shift assessment. Which postoperative finding is immediately reported to the surgeon? a. Some serousanguineous fluid b. Pain along the incision site c. Reluctance or refusal to cough and breathe deeply d. Swelling or bulging at the operative site
d.
A client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? a.Prepare to defibrillate b. Administer lidocaine IVP c. Notify the health care provider d. Check the client's apical pulse
d.
According to Quality and Safety Education for Nurses (QSEN), what is the priority nursing assessment that the nurse should perform every 8 hours to protect a client who has neutropenia? a. Assess client's concerns first and then follow up be addressing each concern and problem b. Perform a focused assessment that includes pain and body system most affected by cancer c. Monitor for complications that are associated with the type of therapy that the client is receiving d. Perform total client assessment and check for common symptoms associated with infection
d.
During the nurse's assessment of a client with Parkinson disease, the nurse notes that the client has mask-like facies. What functional assessment is now priority? a. Ability to hear normal voice tones b. Ability to see in a low light environment c. Ability to sense pain in the facial area d. Ability to chew and swallow
d.
The nurse is caring for a client who must receive a chemotherapy infusion. What is the most important intervention related to extravasation? a. Avoid administering any drugs or fluids that are vesicants to tissue b. Identify the specific antidote and make sure it is readily available c. Advocate that an implanted port be established prior to administration d. Frequently monitor the access site to prevent leakage of large volumes
d.
What is the most common side effect of radiation? a. Altered taste sensation b. Nausea c. Fatigue d. Radiodermatitis
d.
Which of the following is the priority nursing diagnosis for a client with spinal cord injury? a. Impaired adjustment related to depression and body image disturbance b. Self-care deficit related to spinal cord injury c. Impaired physical mobility related to paraplegia d. Impaired urinary elimination related to neurogenic bladder
d. A syndrome that affects the patient with an upper spinal cord injury; characterized by severe hypertension and headache, bradycardia, nasal stuffiness, and flushing; caused by a noxious stimulus, usually a distended bladder or constipation. This is a neurologic emergency and must be promptly treated to prevent a hypertensive brain attack. (Ignatavicius 1731)
During posttest counseling for a patient who has positive testing for HIV, the patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse: a. Inform the patient how to protect sexual and needle-sharing partners. b. Teach the patient about the medications available for treatment. c. Ask the patient to notify individuals who have had risky contact with the patient. d. Remind the patient about the need to return for retesting to verify the results.
d. After an initial positive antibody test, the next step is retesting to confirm the results. The other options are incorrect because: A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals.
A Euro-American male presents to the emergency room with complaints of ascending paralysis and dyspnea. The nurse assesses that the client has decreased deep tendon reflexes. The nurse knows that these symptoms are consistent with which disorder and will anticipate the physician to order: a Huntington's Chorea; Anticholinergic medication b. Multiple Sclerosis; Interferon beta (Avonex) c. Myasthenia Gravis; Pyridostigmine (Mestinon) d. Guillain-Barre syndrome; plasmapheresis
d. Chart 46-1 lists key features of GB (Ignatavicius, p.987)
When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will: a. Ask about problems with diarrhea. b. Examine the oral mucosa for lesions. c. Check neurologic orientation. d. Palpate the regional lymph nodes.
d. Persistent generalized lymphadenopathy is common in the early stage of chronic infection. The other options are incorrect because: Diarrhea, oral lesions, and gait abnormalities would occur in the later stages of HIV infection.
In examining a peripheral IV site, the nurse observes a red streak along the length of the vein and the vein feels hard and cordlike. What is the nurse's next action? a. Apply continuous heat b. Continue to monitor site c. Elevate the extremity d. Remove the IV catheter
d. Phlebitis is the inflammation of a vein caused by mechanical, chemical, or bacterial irritation. Infiltration occurs when IV solution leaks into the tissues around the vein. Patient may report pain at the IV site; nurse may observe that vein appears red and inflamed along the length; vein may become hard and cordlike (Table 15-6) (Ignatavicius 232)
Ten minutes after starting a blood transfusion, the client begins to experience shortness of breath, chills, and a severe headache. What is the nurse's priority action? a. Notify the "code team" of an impending cardiac arrest b. Notify the physician c. Infuse Ringer's Lactate to combat acidosis d. Stop the transfusion
d. Stop the transfusion immediately if a reaction is suspected. Initiate an infusion of 0.9% sodium chloride. The infusion should be initiated with a separate line, so as not to infuse more blood from the transfusion tubing. Save the blood bag with the remaining blood and the blood tubing for testing at the laboratory following agency protocol. (ATI Med Surg, p. 525-526)
Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that: a. The patient is at risk for development of opportunistic infections because of CD4+ cell destruction. b. The patient is in a clinical and biologic latent period, during which very few viruses are being replicated. c. Anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells. d. The body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.
d. The patient is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain the CD4+ count at a normal level. The other options are incorrect because: The risk for opportunistic infection is low because of the normal CD4+ count. Although the viral load in the blood is low, intracellular reproduction of virus still occurs. Anti-HIV antibodies produced by B cells attack the viruses in the blood, but not intracellular viruses.
A patient who is diagnosed with AIDS and has developed Kaposi's sarcoma tells the nurse, "I have lots of thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is most appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Although your diagnosis is serious, there are more treatments available now." c. "Try to focus on the good things in life because stress impairs the immune system." d. "Tell me what kind of thoughts you have about dying."
d. More assessment of the patient's psychosocial status is needed before taking any other action. The other options are incorrect because: The statements, "Thinking about dying will not improve the course of AIDS" and "Try to focus on the good things in life ..." discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. The statement, "Although your diagnosis is serious, there are more treatments available now" is correct, but without further assessment, it is impossible to know whether this responds to the patient's concerns.
What are some types of medications that are used in patient's with Spinal Cord Injuries and Neurologic Shock
dextran atropine dopamine
What is the hallmark sign of Trigeminal Neuralgia
facial pain
What does albumin do?
helps draw fluid into Extracellular space
What does low pressure mean when suctioning? What do you do to fix?
leak (check patient first) manual ventilation (use bag valve mask) and do mechanical valve
What medication is often given for a patient with sleep apnea? What other tx options are there?
modafinil (stimulant) -CPAP/BiPAP
What is the opioid prescription of choice for a new patient receiving PCA
morphine
___________________ measures the viral capsid (core) ______ protein in blood that is detectable earlier than HIV antibody during acute infection.
p24 antigen assay p24
For shock/trauma, what type of blood transfusion will be given?
plasma expanders, RBC
How often should glucose levels be taken when a patient is on TPN/PPN?
q4h
PCA (Patient Controlled Analgesia) pumps should not be used in patients for...
respiratory/sleep apnea (especially w/ respiratory patients) dependency issues
Polysomnography is the test used to diagnose a patient with _____________?
sleep apnea
What are the signs and symptoms of unstable (symptomatic) A. Fib.? How is this treated?
-Decrease LOC, decrease BP, decrease UO -Cardioversion
If a patient is experiencing Ventricular Fibrillation, what interventions need to be taken?
-Defib -CPR -Antidysrhythmias (amiodarone, epinephrine) (maybe diltiazem, lidocaine, vasopressin)
What is the main difference between Sinus Tachycardia and Supraventricular Tachycardia?
It is hard to see the "P wave" on SVT, but it's there. Looks like there is a P and T wave.
If a patient is experiencing SVT and has a steady A. fib, what is the best treatment option?
Medications
Tensilon test is performed to diagnose a patient with ________________.
Myasthenia Gravis
The Tensilon test is used to test patients with ______________.
Myasthenia Gravis
How can you tell the difference between Sinus Tachycardia and Supraventricular Tachycardia?
Narrow QRS (SVT)
How can you determine if a patient is undergoing A. Fib? (EKG)
No distinct P wave
What is going on in the heart with a patient experiencing V.Fib.
No ventricular contraction SA/AV are firing off like fireworks
A synchronized cardioversion is timed to the ______________ wave.
R
How to tell if a patient is undergoing Ventricular Tachycardia (EKG)?
Regular R-R wave "Tombstone"
A client is in ventricular fibrillation. Which interventions should the nurse implement? (Select all that apply.) a. Check the vital signs b. Start cardiopulmonary resuscitation c. Defibrillate the client d. Administer amiodarone IVP e. Administer adenosine IVP
b,c,d
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) a. Verify the prescribed ventilator settings daily. b. Administer pantoprazole as prescribed. c. Elevate the head of the bed to at least 30°. d. Reposition the endotracheal tube to the opposite side of the mouth daily. e. Apply restraints if the client becomes agitated.
a, b, c, d
A client is admitted to the unit and the nurse suspects a cardiac problem. Which interventions should the nurse implement? (Select all that apply.) a. Start saline lock in the right arm b. Draw a basic metabolic panel (BMP) c. Attach telemetry monitor to the client d. Stat 12 lead electrocardiogram e. Obtain a midstream urine specimen
a, b, d
Which interventions by the nurse are essential to prevent an infection in a patient with a central line? (Select all that apply.) a. Assess the dressing and insertion site of the central line. b. Employ aseptic technique when administering medications and changing tubing. c. Change the catheter every 72 hours and tubing every 24 hours. d. Monitor the patient's temperature for any elevation and give acetaminophen as needed. e. Use sterile technique when assisting the HCP with insertion of a central line. f. Use proper handwashing and non-sterile gloves before coming into contact with a central line.
a,b,e,f
A client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? a. Instruct the client to use soft-bristle toothbrush b. Discuss the importance of getting monthly partial thrombosplatin time (PTT) c. Teach the client about signs of pacemaker malfunction d. Explain to the client the procedure for synchronized cardioversion
a.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy? a. Hyperglycemia b. Aspiration c. Diarrhea d. Stomatitis
a.
A nurse is assessing a client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first? a. Stay with the client and document the findings b. Place the client in left lateral recumbent c. Administer morphine intravenous push slowly d. Notify the health care provider immediately
a.
An older client is receiving a blood transfusion. Which signs/symptoms suggest that the client is experiencing transfusion-associated circulatory overload? a. Hypertension, bounding pulse, and distended neck veins b. Fever, chills, and tachycardia c. Urticaria, itching, and bronchospasm d. Headache, chest pain, and hemoglobinuria
a.
The health care provider has ordered an angiotensin-converting enzyme inhibitor (ACEI) for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include in the teaching plan? a. Teach the client how to prevent orthostatic hypotension b. Instruct the client to take a cough suppressant if a cough develop c. Encourage the client to eat bananas to increase potassium level d. Explain the importance of taking the medication with food
a.
The nurse suspects the patient has a pulmonary embolism and notifies the physician. What diagnostic test should the nurse anticipate the physician will order? a. CT scan b. Complete blood count c. Hemoglobin/hematocrit d. Thoracentesis
a.
When providing care for an older client receiving IV fluids through a central line at 150 mL/hr, the nurse finds the client has shortness of breath, cough, puffiness around the eyes, and crackles. What does the nurse do next? a. Place the patient in an upright position, administer oxygen, slow the IV rate, and notify the care provider. b. Assess for patency of the catheter, change the tubing, and resume IV fluids. c. Notify the provider, remove the central line, apply pressure, and place the patient in a semi-Fowler's position. d. Notify the provider, place the patient in Trendelenburg position, and administer urokinase to un-clot the catheter.
a.
The nurse is conducting discharge teaching with a client to reduce the risk for recurrence of a pulmonary embolism. Which statement should the nurse include? a. "Avoid the use of tight garters and constricting clothing." b. "Change your position every 20 minutes." c. "Engage in activities that result in the Valsalva manuever." d. "Use an incentive spirometer every 2 hours while awake."
a. Avoid the use of tight garters, girdles, and constricting clothing. (Ignatavicius 663)
Which medical treatment would be prescribed for the client with an abdominal aortic aneurysm (AAA) less than 3cm? a. Ultrasound every six (6) months b. Intravenous pyelogram yearly c. Assessment of abdominal girth monthly d. Repair of abdominal aortic aneurysm
a. When aneurysm is small (<5-6 cm) an abdominal sonogram will be done every 6 months until the aneurysm reach a size at which surgery to prevent rupture is of more benefit than possible complications of an AAA repair. The other options are incorrect because the intravenous pylogram evaluates the kidneys, the abdomen will not distend as the AAA enlarges, this AAA is too small to perform surgery to remove.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH-7.22 PaCO2-68 mm Hg Bicarbonate-26mEq/L, Base excess -2 PaO2-78 mm Hg, Saturation 80% a. Metabolic alkalosis b. Respiratory acidosis c. Respiratory alkalosis d. Metabolic acidosis
b.
A client is admitted to the unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs and symptoms would the nurse expect to find when assessing this client? a. Thick white sputum and crackles that clear with cough b. Apical pulse rate of 110 and 4+ pitting edema c. Radial pulse rate of 90 and capillary refill time <3 seconds d. The client sleeping with no pillow and eupnea
b.
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) a. Nausea b. Hypotension c. Headache d. Decreased level of consciousness e. Severe dyspnea
b, c, d, e
A client with coronary artery disease (CAD) asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? a. "The heart muscle is unable to pump effectively to perfuse the body." b. "Chest pain is caused by decreased oxygen to the heart muscle." c. "Chest pain occurs when the lungs cannot adequately oxygenate the blood." d. "There is ischemia to the myocardium as a result of hypoxemia."
b.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? a. Chest tube drainage b. Arterial blood gases c. Pain level d. Urinary output
b.
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? a. Excessive thirst and urination b. Shakiness and diaphoresis c. Fever and chills d. Hypertension and crackles
b.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? a. Assess for indication of pulmonary embolism b. Administer oxygen via face mask c. Prepare for mechanical ventilation d. Prepare to administer a sedative
b.
Which electrolyte imbalance can occur related to a blood transfusion? a. Hyponatremia b. Hyperkalemia c. Hypocalcemia d. High blood glucose
b.
Which assessment data support the diagnosis of abdominal aortic aneurysm (AAA)? a. Shortness of breath b. Abdominal bruit c. Ripping abdominal pain d. Decreased urinary output
b. A systolic bruit over the abdomen is diagnostic of AAA. SOB indicates a respiratory problem. Ripping and tearing pain indicates a dissecting aneurysm, urine output is not diagnostic of AAA.
The nurse observes the nursing student suctioning the client. Which intervention performed by the student has the greatest potential to cause tissue damage? The student nurse: a. hyperoxygenated the client after suctioning for 2 minutes until the client's HR and O2 saturation returned to baseline. b. suctioned the client for 45 seconds c. oxygenated the client with 100% oxygen for 2 minutes prior to suctioning d. did not apply suction during insertion of the catheter
b. Apply suction intermittently for only 10 to 15 seconds. Estimate this time frame by holding your own breath and counting to 10 or 15 during suctioning. After 15 seconds, end the suctioning procedure. Most patients cannot tolerate more than 15 seconds of suctioning. Prolonged suctioning can cause alveolar collapse (suction atelectasis). (Ignatavicius 575)
The nurse is caring for a client that goes into ventricular tachycardia. Which intervention would the nurse implement first? a. Call a code immediately b. Assess the client for a pulse c. Begins chest compressions d. Continue to monitor the client
b. The nurse must first determine if the client has a pulse; Remember that you must assess your pt first, it is the first step in the nursing process. The nurse should call a code if the client does not have any vital signs. Chest compression is only done if the client does not have a pulse and is not breathing. Ventricular tachycardia is a potentially life threatening dysrhythmia and must be treated immediately
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? a. Prepare to insert a central line. b. Remove the dressing to inspect the wound. c. Administer oxygen via nasal cannula. d. Raise the foot of the bed to a 90° angle.
c.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? a. Crepitus in the area above and surrounding the insertion site b. Equal breath sounds bilaterally c. Movement of the trachea toward the unaffected side d. Bubbling of the water in the water seal chamber with exhalation
c.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? a. Check the suction control outlet on the wall. b. Check the tubing connections for leaks. c. Continue to monitor the client's respiratory status. d. Clamp the chest tube.
c.
A patient has a peripherally inserted central catheter (PICC) placed by an IV therapy nurse at the bedside. Before using the catheter, how is its placement verified? a. The provider who ordered the procedure verifies placement. b. The line is aspirated gently, and the nurse watches for blood return. c. A chest x-ray is taken, which shows the catheter tip in the lower superior vena cava. d. The line is slowly flushed with 10 mL of saline while the nurse notes the ease of flow.
c.
Which intervention should the nurse implement when administering loop diuretic to a client diagnosed with heart disease? a. Assess the client's capillary blood glucose level b. Assess the client's radial pulse c. Assess the client's potassium level d. Assess the client's pulse oximetry reading
c.
Which patient has the greatest risk for developing a febrile transfusion reaction? a. Patient is an older adult, and transfusion was given too rapidly. b. Patient received an intra-operative autologous transfusion. c. Patient has received multiple blood transfusions for chronic bleeding. d. Patient sustained multiple injuries and needed an emergency transfusion.
c.
A client scheduled to have a total laryngectomy asks the nurse what changes to expect in voice quality after the surgery. What is the nurse's best response? a. "You will not be able to speak above a whisper." b. "Your permanent voice will be hoarse and breathy." c. "The removal of your larynx results in permanent loss of natural speech." d. "Speech will return to normal within 6 months."
c. A total laryngectomy is removal of the entire larynx, hyoid bone, strap muscles, one or two tracheal rings removed, which results in no natural voice. (Ignatavicius 592)
The client has just undergone insertion of a central venous catheter at the bedside. The nurse should check which result before initiating the flow rate of the client's IV solution at 125 mL/hr? Group of answer choices a. Serum osmolality b. Electrocardiograph c. Portable chest x-ray d. Serum sodium level
c. Central catheters require x-ray verification of tip placement prior to use. (ATI, Med Surg, p. 361)
The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as: a. sinus tachycardia. b. atrial fibrillation. c. ventricular tachycardia. d. ventricular fibrillation.
c. The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate ventricular tachycardia. The other options are incorrect because Atrial fibrillation is grossly irregular, has a narrow QRS configuration, and has fibrillatory P waves. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Hemothorax c. Pneumothorax d. Flail chest
d.
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? a. Add more water to the suction control chamber of the drainage system. b. Milk the chest tube and dislodge any clots in the tubing that are occluding it. c. Continue to monitor the client as this is an expected finding. d. Verify that the suction regulator is on and check the tubing for leaks.
d.
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse? a. The pulse oximeter reading is 96% b. The urine output is 240 mL in the last six (6) hours c. Bilateral peripheral pulses 2+ d. Cold, clammy, and diaphoretic skin
d.
The client who was admitted for GI bleeding has a syncopal episode while getting up to the bedside commode. Lab values are: HGB - 6.8, Hct - 23.9, platelets 180,000. The provider orders the following blood products to be transfused immediately. The nurse's priority to transfuse: a. 4 packs of platelets b. 1 unit of fresh frozen plasma (FFP) c. 1 unit of cryoprecipitate d. 2 units of packed red blood cells (PRBC)
d.
While assessing a client's IV site, the nurse identifies signs and symptoms of infiltration. What is the first action that the nurse implements for this client? a. Elevate the extremity. b. Apply a sterile dressing if weeping from the tissue has occurred. c. Remove the IV access. d. Stop the IV infusion.
d.
The client is diagnosed with pericarditis. Which signs/symptoms the nurse would expect to find when assessing the client: a. Pulsus paradoxus b. Complaints of fatigue and arthralgia c. Petechial and splinter hemorrhages d. Increased chest pain and inspiration
d. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset and is aggravated by respiratory movemmetns (deep breathing, coughing), changes in body position and swallowing. The other options are incorrect because pulsus paradoxis is the hallmark of cardia tamponade; fatigue and arthralghias are nonspecific signs that usually occuyr with myocarditis; and petechial & splinter hemmorages occur with endocarditis.
Which of the following are signs & symptoms of circulatory overload? a. dyspnea, chest tightness, & tachycardia b. tachypnea, headache, & jugular vein distention c. orthopnea, sudden anxiety, & crackles at lung bases d. all of the above
d. Clients with impaired cardiac function can experience circulatory overload as a result of a transfusion. Signs and symptoms include - dyspnea, chest tightness, tachycardia, tachypnea, headache, hypertension, jugular-vein distention, peripheral edema, orthopnea, sudden anxiety, and crackles in the base of the lungs. (ATI, Med Surg, p. 526) (Iggy p 901)
